Provider Demographics
NPI:1578305256
Name:POTOMAC VALLEY HOSPITAL OF WV, INC.
Entity type:Organization
Organization Name:POTOMAC VALLEY HOSPITAL OF WV, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOUCOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-597-3510
Mailing Address - Street 1:100 PIN OAK LN
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-5908
Mailing Address - Country:US
Mailing Address - Phone:304-597-3532
Mailing Address - Fax:304-597-3536
Practice Address - Street 1:566 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2937
Practice Address - Country:US
Practice Address - Phone:304-788-6685
Practice Address - Fax:304-788-5412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POTOMAC VALLEY HOSPITAL OF WV, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty